S 0924 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PBM4ITNO, 0924
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEMI'IFICATION
BUILDING ADDRESS, SANT fARY NO. AI'I'LICAI'ION SUBMITTAL DATI
7 W A er Ford D Y ���
OWNF,R'SN Mli: PHONE: CO CFOR'S NAMF,;�, `� LICyD
V w��_ a til J Y O NIC CONTROLp
• ARCHITECT/ENGINEER: LICNOt ADDWjSSU�
. 8 �_ ❑
CONTACT: PHONE: YY BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B )G ELECT rI UMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT I'EE
1 herehy air,.that I am licensed under provisions of Chapter 9lcnmmencing JOB DESCRIPTION
O�Z with Satian]IX0)ofDivinion Atfhe Business and Prnfe int rule,and myliccnne is
¢I O O T PERMIT ISSUANCIi
FYI full force end elf / G SFDWL C1 KITCHEN REMODEL
aV�j Liennse I^e Liap C APPLIANCES-RESIDEN'T'IAL ❑ADDITION El PLUMBING RE-PIP171
27
H'y W Dam Gmvxcmr
r/IQ6 ❑MULTI-UNIT [I STRUCTURAL
ARCHITECTS DP.CLARA'rION
Z O s� 1 understand my plana shall be amd as public records PANELS MODIFICATION
OZ-0 UP TO 201 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-V F' Licensed Pomfeconal 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
CLARATION
9 W� I hereby a n.tiro 1 am exempt froR OWNER-BUILDERm he Contractor's License Lew for the OVER I"AMPS (BATH REMODEIJRE,P.AI,.R'❑DEMO�LI
qqq 06 Vm p following reason.OSechi ]031.5,Business and Professions Code:Any city err county SIGNS ELECTRICAL El OTHER f j
DEMOLITION
ONwhich.,arm,.permit to monuuct,ahee improve,demolish,or repair any structure
J prior to its issuance,also requires the applicant for such permit m file a signed smmmcm SPECIAL CIRCU IT/MISC.
;h!jai¢ that he is licensed pursuant tithe provi.vionsol'the Contractors License Law(Chapte it COMMERCIAL;
apo (varnamcing with S.fm7000)mf Division 3 o(he Business and Professions Cale)or TEMP.METER OR POLE INST.
d[iV5 e ys that he is exempt herefrnm and the basis far the alleged exemption Any viulminn of [I NEW BLDG/ADDI'TION ❑DEMOLITION
W^m
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
ZqD• narmretlmn five hundred dollars($50X1). IMPROVEMENT
2Qp C] I,as owner of the portray.or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC
p. will do he work.and theorcmre is not intendeloruRared for sate(Sec71H4.Business [I OTHER
E 3 E and Professions Code:Use Conlmcmds License Law does nal apply us an owner of OUTI.CTS-SWITCHES-FIXTURES
property who builds or improves theme,and who does such work himself or through
his own employees,provided thin such improvements arc tent intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.IL however,the building or improvement ixsold within one year ofcompletfon,the SQ.PT.FLOOR AREA $/SQ.FT,
cr-builder will have the banes of proving that he did nm build or improve far par- ®V
p au of salon. -/I {/t.pt11
nm
❑hasowner mfthe ct(See cny,ameanessiv ad contracting wihlicTheedcontrectors i- TO L: �I aW/�J
answer he project(Su:.o an Business and rty whoi ins s or
The Canmemon. nd
se Law does nrnapply aress with
acofpropeny whohuildsnr improveshereon.and QTY. PLUMBING FERMI FEE '�Uf LVr
who nsmrvets for such projects with aconwmor(s)licensed punuam mthe Commnats _ t�IIryV
License Liev. PERMIT ISSUANCE
❑I am axempt under See .B&P C forhis..,on
Owner Data
ALTER-DRAIN&VENT-WATER lE VALUATION
�s..���
U V
• WORKER'S COMPENSATION DECLARATION RACK FLOW PRTITCT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarations: (� 7
Psi have and will maintains Cenifeveof Consent to self-insum for Workers Compes- DRAINS-FLOOR,ROOF,AR EA.CONE), STORIES TYPE.CONSTRUCTION
union,as provided for by Section 37M of he Labor Cade,lir he Ixrfomance of the
work far which this Achim,is issued. FIXTURES-PER'rRAP
I have and will maintain Workers Compensation Insumnca,as reymo d by Section
3]0fl of the Labor Gne,for he performance of the work for which this permit is isstQmd OAS-GA.SYSTEM-I INC.40U'TLETti OCC.GROUP APN
My Worke5ZA�In G� y Policy No.�n��'(/����4-• GAS-EA.SYSTEM-OVIiR4(UN
Cameo 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINDIISTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ttixsemien need not becompleadifheptwit isfornnehundreddoliers($IW) GREASF.TRAP
err less) PLANCNECK Pf:H.
I certify hot in the performance ofihe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2001 FT.
not employ any person in any manner so as to become subject the Workers Compen- ENERGY FEE
Z ,Z, moor Laws of C.1chania.Date WATIiR HEAl1iR W/VENT'/ELECHR
2 Applicant 1 GRADING PEE
ti NOTICE TO APPLICANT.If,after making this Cmifiene of Exemption,you should WATER SYSTLM/FREATING SOILS FEE
a , become subject m the Worker's Compensation provisions of Ibe Labor Gale,you cars)
Ira forthwith comply with such provisionsor this pennt shall be deerned resumed. WATER SERVICE
Q
Usz CONSTRICTION LENDING AGENCY NEW RESIDIlSTIALPLMII. SQ.FT. PAID Dem xipte
V khereby wafftm the here iaaed(Sec.30 lending agency for performance of
f~-s the ices far which his permit is ismted(Sec.3097.On.C.)
� fenders Name TOTAL'
WLeadcrs Address TBUILDINGP
C 1 emil'y that I have read this application and state that the move information is
V) correct.l agree to comply with all city and county ordinances and nam laws relating to QTY, MECHANICAL PERMIT FEE
U �. building construction,and hereby authnom repreunmelves aphis city tar enter upondm SEISMIC PEE
tr above-mentioned popery far inspection purposes. PERMIT ISSUANCE(We)agree us save,indemnify and keep harmless the City of Cupenino against F.LGCTRIC FE
liabilities,judgments,costs and expenses which may many way accrueagainat said Chy ALTEMORADDTOMF.CH.
in consequence of the geeing of this permit PLUMBINGF Ii
APPLICANT NUERSTANDS AND ILL COM PLY WO If ALL NON-POINT AIR HANDLING UNIT 0'010.00 CFM)
SOURCE ULATIONS. MECHANICAL OiE
I Q AIR HANDLING UNIT(OVER RkWOCFM)
cJ CONSTRUCTION TAX
marc.(Applicant/ ontrxchu Date EXHAUST HOOD I WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MA'I'FRIAI S DISCLOSURE
Will he applicant or famrt building occupant store or handle moondams materiel HEATING UNIT(TO 100J61)BTU)
as tamed by the Cupenino Municipal Code,Chapter 212.and the Health and Safety
Cade,Section 25532(,)7HEATING UNIT(OVER 100,00 BTU)
❑Yes 1 Nn VENTILATION FAN(SINGLE RESID) PAID
Data Receiptp
Will the applicant sons a building by he B use equipment err devices which
emit hamnlnus air canmminunu as JefneJ by he Bay Area Air Quality Management BOILER-COMP(11 IV OR If0.010 BTlll TOI,kL
Dintricr4
E]Yex BOILER-COMP(OVER 100,0X0 BTU)
� n -
I have read the hamanous me¢duls is under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE.
5,255 fnmin Health&Safety Cale,Sections 2551)5,2,5my and 8 slit,undersand(her if the NEW RESIDENTIAL MECH. SQ.PI'. �\
of the
remly haveul am til i.no c off i emarc notify the pccupam //u l) //s
of the myuircn s is ems tun onnisst cn(a Q•nificatenf lkcupanc v
Own seat ed agent �l Dam f 'TOTAL: ISSUED ITV SM
OFFICE
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